The management of the NHS has been characterised by two trends in recent years. Firstly, there has been the increasing dominance and assertiveness of the NHS Management Executive, with ever tighter control from the centre. Secondly, there has been soaring spending on managerial staff and information technology. Both have been much criticised. Both have been justified on the grounds that tighter central control and a strengthened system of management are required in the interests of efficiency and accountability: the investment, it is claimed, will justify itself by bringing about greater productivity and promoting value for money. A large question mark has now been put against these arguments by the two much publicised reports from the Committee of Public Accounts of the House of Commons, dealing with the affairs of the Wessex 1,2 and West Midlands regional health authorities.3,4

In the case of Wessex, the Committee of Public Accounts was investigating the loss of an estimated pounds sterling 20 million (and perhaps much more) which followed an unsuccessful attempt to introduce a regional information system. In the case of the West Midlands, the committee was inquiring into the loss of an estimated pounds sterling 10 million wasted in the operations of the regionally managed services organisation. The scale of the losses is, in itself, staggering.

More serious is the state of affairs revealed in the two reports. For the common thread linking the two inquiries is a loss of managerial control and accountability. In both cases the regional …